AGA Clinical Practice Update on Management of Ostomies: Commentary
Authors: Traci L. Hedrick, Alexis Sherman, Shirley Cohen-Mekelburg, Jill K.J. Gaidos
Journal: Clinical Gastroenterology and Hepatology (2023)

DescriptionThe purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update (CPU) is to review the available evidence and provide expert advice regarding the management of patients with an enteral stoma.MethodsThis CPU was commissioned and approved by the AGA Institute Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of a multidisciplinary group of authors composed of gastroenterologists, a colorectal surgeon, a wound ostomy and continence nurse, and ostomate. The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update (CPU) is to review the available evidence and provide expert advice regarding the management of patients with an enteral stoma. This CPU was commissioned and approved by the AGA Institute Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of a multidisciplinary group of authors composed of gastroenterologists, a colorectal surgeon, a wound ostomy and continence nurse, and ostomate. Enteral ostomies are common in the management of patients with gastrointestinal conditions, including colorectal cancer (CRC), inflammatory bowel disease (IBD), diverticular disease, intestinal trauma, and intestinal perforation. An estimated 750,000 Americans live with an ostomy and 130,000 new ostomy surgeries occur in the United States annually.1The Wound, Ostomy and Continence Nurses Society, Guideline Development Task ForceWOCN Society Clinical Guideline: management of the adult patient with a fecal or urinary ostomy-an executive summary.J Wound Ostomy Continence Nurs. 2018; 45: 50-58Crossref PubMed Scopus (70) Google Scholar People with ostomies often face postsurgical complications and challenges to daily self-care. Studies have suggested that adequate stomal care improves clinical outcomes and reduces hospitalizations.2Kim Y.M. Jang H.J. Lee Y.J. The effectiveness of preoperative stoma site marking on patient outcomes: a systematic review and meta-analysis.J Adv Nurs. 2021; 77: 4332-4346Crossref PubMed Scopus (16) Google Scholar However, little guidance exists to support clinicians in managing patients with an ostomy beyond the immediate perioperative period. There are several different types of ostomies, each with their unique set of challenges. The focus of this commentary is on the enteral stoma (ie, colostomy or ileostomy) (Figure 1). The most common type of enteral stoma is the colostomy, a stoma created from a portion of the colon. Common indications for colostomy include CRC, diverticulitis with perforation, trauma, Crohn's disease, and the need for fecal diversion (in the setting of fecal incontinence, a sacral wound, or spinal cord injury). Most colostomies are constructed from the sigmoid, descending, or transverse colon. The right side of the colon usually is avoided for colostomy creation given its large diameter and liquid effluent leading to a large stoma that is prone to leakage. The output from a colostomy typically is formed with bowel movements commonly occurring once daily, making the output easier to manage than that of an ileostomy. Colostomy appliances usually are changed once every 6 to 7 days. Ileostomies are constructed out of the terminal ileum close to the ileocecal valve to maximize nutrient absorption. Common indications for ileostomy include CRC, IBD, and colonic dysmotility. Ileostomies are easier to construct and reverse but are associated with more dehydration and skin excoriation than colostomies. The liquid effluent from an ileostomy generally warrants emptying 3 to 4 times daily and changing the wafer every 4 days on average. Enteral stomas are created in either a loop or end configuration (Figure 1). With any technique, it is important for the stoma to sit above skin level so the effluent does not seep under the appliance.3Davis B.R. Valente M.A. Goldberg J.E. et al.The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for ostomy surgery.Dis Colon Rectum. 2022; 65: 1173-1190Crossref PubMed Scopus (11) Google Scholar The suturing technique enabling the stoma to protrude above the skin is referred to as the Brooke technique. An end stoma is created when the intestine is divided and the proximal end is brought out as a stoma while the distal end is left within the abdomen. Rarely, the distal, defunctionalized end of the intestine also is brought out to the skin through a separate incision (known as a mucus fistula). The mucus fistula generally is avoided when possible because it results in 2 separate stomas/abdominal wall defects. However, the mucus fistula may be required in situations when there is significant risk of a leak in the stapled off end (eg, distal obstruction or poor tissue integrity). The end stoma is the easiest stoma for patients to pouch and is used most often in the setting of a permanent stoma or in the case of an intestinal perforation requiring resection. A loop ostomy is created by bringing a continuous piece of intestine through the abdominal wall and opening the anterior wall, resulting in 2 intestinal openings side by side within the same skin aperture. The loop ostomy usually is constructed such that the active proximal end (which drains stool) is made dominant (Brooked), while the defunctionalized distal end is diminutive. A loop ostomy is created when there is a distal obstruction (such as an obstructing cancer) to both alleviate the obstruction and permit drainage of mucus and retained stool within the distal segment. As opposed to the mucus fistula, creation of the loop ostomy is accomplished through a single stomal aperture and does not require resection or division of the intestine. A loop ostomy also frequently is used when a temporary diversion is needed (eg, to protect a distal anastomosis, or allow healing of a sacral decubitus, and so forth). The loop ostomy is relatively easy to create and reverse (given both pieces of intestine are at the skin level), whereas an end stoma reversal requires a more invasive surgery to locate the stapled-off distal end within the abdomen. The continent ileostomy (also known as the Kock pouch or the Barnett Continent Intestinal Reservoir) is a stoma that uses an internal pouch made of pleated intestine to create a nipple valve in the efferent limb, preventing the passage of stool through the ostomy until intubated with a catheter.4Kayal M. Rubin P. Bauer J. et al.The Kock pouch in the 21st century (with videos).Gastrointest Endosc. 2020; 92: 184-189Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar In most cases, patients with a continent ileostomy do not need to wear an appliance. This type of ostomy is uncommon because of the high rate of complications leading to revision surgery and intestinal loss.5Nessar G. Wu J.S. Evolution of continent ileostomy.World J Gastroenterol. 2012; 18: 3479-3482Crossref PubMed Scopus (34) Google Scholar Early high ostomy output (HOO) is defined as ostomy output greater than fluid intake (typically >1.5 L/d) occurring within 3 weeks of stoma formation, resulting in dehydration. This is common for patients with an ileostomy but rarely occurs with a colostomy.6Shah P.M. Johnston L. Sarosiek B. et al.Reducing readmissions while shortening length of stay: the positive impact of an enhanced recovery protocol in colorectal surgery.Dis Colon Rectum. 2017; 60: 219-227Crossref PubMed Scopus (59) Google Scholar Prompt evaluation for infection (eg, postoperative abdominal infection, Clostridioides difficile), ileus, or medication-related adverse effects is indicated in the context of a colostomy or high ileostomy output. The most important treatment for HOO is hydration to prevent renal failure. Because of the large volume of fluids needed for repletion, these typically are given intravenously, requiring hospital admission or long-term intravenous access placement for home health care. If the HOO persists, early reversal of the stoma should be considered, although reversal before 6 weeks of the index surgery is associated with an increased risk of complications. Medical treatments of early HOO are described in Table 1.Table 1Treatment Strategies for High Ostomy OutputType of treatmentExamplesBulking agentsPsyllium fiberGuar gumMarshmallows9Rowe K.M. Schiller L.R. Ileostomy diarrhea: pathophysiology and management.Proc (Bayl Univ Med Cent). 2020; 33: 218-226PubMed Google ScholarAntimotility agentsLoperamideDiphenoxylate and atropineCodeineTincture of opiumAntisecretory agentsProton pump inhibitors/H2 agonistsSomatostatin analogues (ie, octreotide)Anti-inflammatory agents (if resulting from recurrent Crohn's disease)Consultation with IBD specialistAdaptation-promoting agentsGLP-2 analogues (teduglutide, elsiglutide, glepaglutide, apraglutide)SurgicalReversal of the ostomy with restoration of intestinal continuity when possibleGLP-2, glucagon-like peptide 2; IBD, inflammatory bowel disease. Open table in a new tab GLP-2, glucagon-like peptide 2; IBD, inflammatory bowel disease. One of the most common and dreaded stomal complications is leakage. Certain factors predispose the patient to stomal leakage including obesity, placement within a skin crease, loop configuration, liquid effluent typically associated with an ileostomy or in the setting of chronic diarrhea, and when the stoma is flush with the skin. The best strategy is prevention, specifically preoperative marking by a stomatherapist and meticulous surgical technique. Repetitive leakage of effluent onto the skin can cause significant excoriation from frequent appliance changes, leading to pain, pouching difficulties, and considerable added expense, which can lead to financial hardship. Management steps involve thickening the stool with antidiarrheals to facilitate a more solid effluent and pouching techniques to bolster the height of the stoma off the peristomal skin (eg, convex appliance, ostomy belt, paste, or barrier rings). Each of these items is available through the patient's medical equipment supplier. Additional pearls include heating the appliance with a hair dryer before application, lying flat for several minutes after application, ensuring the peristomal skin is dry before application, and use of a fine dusting of stomal powder followed by skin sealant on the peristomal skin before application. Leakage is more common in the early postoperative period but also can develop later with changes in body habitus owing to weight loss/gain and pregnancy. The appliance opening should be cut one-eighth inch larger than the stoma to prevent irritation of the mucosa while limiting the skin surface exposed to the effluent. Stoma size should be measured at each appliance change for the first 8 weeks because the stoma shrinks in the intervening weeks after surgery. Refractory cases of ostomy leakage may require ostomy revision. Stomal retraction can occur when the ostomy becomes ischemic or in obese patients, in whom pulling the stoma through a thick abdominal wall to skin level at the time of creation can be challenging. If the stoma retracts below the level of the abdominal wall in the early postoperative period, this can lead to sepsis and the need for emergent surgical revision. More commonly, the stoma retracts within the skin but remains above the fascia, leading to long-term pouching issues and stricture. Endoscopy or cross-sectional imaging may help delineate the depth of ischemia/retraction. In the patient with a temporary stoma, retraction typically is managed symptomatically with a convex appliance, ostomy belt, and barrier ring until the stoma can be reversed, whereas revision (either local revision or more complex revision with laparotomy) often is necessary in the setting of a permanent stoma. At the time of ostomy creation, the stoma is matured by suturing it to the skin with absorbable sutures. In some cases, these sutures detach and the stoma separates from the skin. This creates an open wound that can be managed with various different pouching solutions until the wound heals by secondary intention. Patients on immunosuppressive medications are at particular risk for mucocutaneous separation given the negative impact on wound healing. Most commonly, peristomal skin issues result from leaking around the appliance and can be managed accordingly (see Ostomy leakage section above). Additionally, patients may develop allergies to the ostomy appliance, fungal rash, and/or folliculitis. Allergies typically present with itching and redness that takes the shape of the offending product. Application of skin sealant can help with minor irritation, although changes to the pouching system and temporary use of steroid spray may be required. Prolonged moisture and heat under an appliance can lead to a fungal infection, which presents as an itchy maculopapular rash with satellite borders. Antifungal powder can be sprinkled onto the skin and sealed with sealant. If there is no improvement after 2 weeks, patients should be evaluated further by a surgeon or enterostomal therapist. Patients (particularly those with IBD) presenting with painful ulcers surrounded by a purple halo should be assessed for possible peristomal pyoderma gangrenosum.7Lyon C.C. Smith A.J. Beck M.H. et al.Parastomal pyoderma gangrenosum: clinical features and management.J Am Acad Dermatol. 2000; 42: 992-1002Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar Pyoderma gangrenosum requires interdisciplinary care by gastroenterology, dermatology, and wound care nursing.8Uchino M. Ikeuchi H. Matsuoka H. et al.Clinical features and management of parastomal pyoderma gangrenosum in inflammatory bowel disease.Digestion. 2012; 85: 295-301Crossref PubMed Scopus (19) Google Scholar Given the vascular nature of the stoma, a small amount of bleeding during appliance changes is normal. However, if bleeding persists or becomes severe, a work-up for peristomal varices should be considered. This typically is characterized by a purplish, concentric discoloration around the ostomy. Chronic or late HOO is defined as persistent HOO for more than 3 weeks after surgery or new-onset HOO occurring more than 3 weeks after ostomy creation. Chronic HOO is more likely to occur with a jejunostomy, in patients with short bowel (defined as having <200 cm of small intestine remaining), or in patients whose small bowel fails to adapt after surgery. Adaptation after creation of an ileostomy generally starts to occur over days to weeks, resulting in changes in the mucosa leading to alterations in electrolyte transport, absorptive capacity, and motility.9Rowe K.M. Schiller L.R. Ileostomy diarrhea: pathophysiology and management.Proc (Bayl Univ Med Cent). 2020; 33: 218-226PubMed Google Scholar The etiology of late HOO can include infection, structural problems (ie, stomal stricture or dysfunction, intestinal obstruction, ileus, or enteric fistula), recurrent Crohn's disease, and other common etiologies of diarrhea in adults (ie, microscopic colitis, bile acid diarrhea). A list of medical treatments for chronic HOO can be found in Table 1. Parastomal hernia is common given that the stoma formation creates a defect in the abdominal wall that can enlarge over time as a result of intra-abdominal pressure and can occur in up to 50% of ostomates within 5 years.10Antoniou S.A. Agresta F. Garcia Alamino J.M. et al.European Hernia Society guidelines on prevention and treatment of parastomal hernias.Hernia. 2018; 22: 183-198Crossref PubMed Scopus (199) Google Scholar Obesity, smoking, steroid use, and transverse colostomies increased the risk for hernia formation. At the time of creation, stomas should be placed through the rectus to minimize the risk of hernia formation.3Davis B.R. Valente M.A. Goldberg J.E. et al.The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for ostomy surgery.Dis Colon Rectum. 2022; 65: 1173-1190Crossref PubMed Scopus (11) Google Scholar When possible, the use of the transverse colon should be avoided because the risk of hernia and prolapse is significant. Incarcerated hernia refers to a painful hernia that cannot be reduced, leading to obstruction and eventual ischemia of the involved bowel loops. This is a surgical emergency. Small, reducible parastomal hernias can be managed with a hernia belt that can be ordered through the patient's medical equipment supplier. Elective repair generally is reserved for patients with significant pouching issues, pain, or recurrent bowel obstruction. The most effective parastomal hernia repair is reversal of the ostomy when possible. Otherwise, parastomal hernia repair often can be accomplished through a minimally invasive approach and frequently requires the use of mesh to reduce the risk of recurrence. Unfortunately, however, recurrence after repair is common (>25% at 2 years).11Miller B.T. Krpata D.M. Petro C.C. et al.Biologic vs synthetic mesh for parastomal hernia repair: post hoc analysis of a multicenter randomized controlled trial.J Am Coll Surg. 2022; 235: 401-409Crossref PubMed Scopus (11) Google Scholar Although it used to be common practice to move the stoma when repairing a parastomal hernia, this has fallen out of favor given the significant risk of parastomal hernia in the new location. As opposed to a parastomal hernia, which is a bulge in the skin and soft tissue surrounding the ostomy, prolapse refers to the elongation of the intestinal portion of the stoma. The rate of stomal prolapse is 5% to 10%.12Shabbir J. Britton D.C. Stoma complications: a literature overview.Colorectal Dis. 2010; 12: 958-964Crossref PubMed Scopus (282) Google Scholar Acute prolapse can lead to incarceration and ischemia, which presents as pain, obstipation, and purple/black discoloration of the stoma. This requires emergency surgery. In the absence of ischemia, the prolapse may be reduced by laying the patient in a relaxed position and gently squeezing the ostomy back into the abdomen. If the stoma cannot be reduced with pressure alone, a cup of sugar applied directly to the stoma and left in place for 20 minutes can reduce stomal swelling and facilitate reduction of the prolapse. Surgery can be avoided if the prolapse is mild, easily reducible, and does not interfere with pouching. Stomal revision or reversal (when feasible) is otherwise indicated in the presence of symptomatic prolapse, incarceration, or ischemia. The psychological impact that ostomy creation has on patients should not be forgotten. Concerns regarding fear of leakage; odor; disclosure to partners, family, and friends; clothing; intimacy; travel; and difficulty with self-care should be addressed through preoperative and postoperative education. Preoperative education and stoma site marking has been shown to improve quality of life and decrease peristomal skin and pouching complications.2Kim Y.M. Jang H.J. Lee Y.J. The effectiveness of preoperative stoma site marking on patient outcomes: a systematic review and meta-analysis.J Adv Nurs. 2021; 77: 4332-4346Crossref PubMed Scopus (16) Google Scholar Most facilities have dedicated wound ostomy and continence (WOC) services available to patients in the perioperative setting. Marking allows for the abdomen to be assessed in multiple positions for a site within the rectus muscle, and away from scars, skin folds, bony prominences, and the umbilicus. One key aspect of WOC consultation is discussing and managing expectations for life with an ostomy, including managing ostomy output, maintaining pouching appliances, and the regular passage of mucus from the native rectum. There are a number of national resources for patients including community-based and online ostomy support groups (Supplementary Figure 1). High-quality ostomy care begins at the preoperative visit with WOC consultation. Stoma education and counseling are essential to prevent complications and manage patient expectations for living with a stoma. The early diagnosis and management of both early and late ostomy complications require ongoing communication between patients and care teams. Multidisciplinary coordination is imperative to prevent hospital readmissions and to improve the quality of life for our patients living with ostomies.